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 Table of Contents  
ORIGINAL RESEARCH REPORT
Year : 2022  |  Volume : 19  |  Issue : 1  |  Page : 22-30

Knowledge, attitude, and prescribing practices of antimicrobials among doctors in the outpatient departments of Lagos university teaching hospital Idi-Araba: A cross sectional study


1 Department of Community Health and Primary Care, Faculty of Clinical Sciences, College of Medicine, University of Lagos, Lagos, Lagos; Department of Family Medicine, Lagos University Teaching Hospital, Idi-Araba, Nigeria
2 Department of Community Health and Primary Care, Faculty of Clinical Sciences, College of Medicine, University of Lagos, Lagos, Lagos, Nigeria
3 Department of Surgery, College of Medicine, University of Lagos and Lagos University Teaching Hospital, Idi-Araba, Nigeria
4 Department of Microbiology, College of Medicine, University of Lagos and Lagos University Teaching Hospital, Idi-Araba, Nigeria
5 Department of Family Medicine, Lagos University Teaching Hospital, Idi-Araba, Nigeria
6 Department of Medicine, Lagos University Teaching Hospital, Idi-Araba, Nigeria

Date of Submission09-Sep-2021
Date of Acceptance28-Jan-2022
Date of Web Publication07-Mar-2022

Correspondence Address:
Dr. Babatunde Akodu
Department of Community Health and Primary Care, Faculty of Clinical Sciences, College of Medicine, University of Lagos and Lagos University Teaching Hospital, Idi-Araba, Lagos
Nigeria
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jcls.jcls_32_21

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  Abstract 


Background: Antimicrobial prescription becomes inappropriate when there is overprescribing, unsuitable dosage and when patients do not complete their treatments. In the outpatient settings, irrational prescription of antibiotics is more evident and has led to the development of resistance, adverse reactions, and increased health care costs. Understanding the knowledge, driving forces and practices of prescribing antibiotics is a step towards ensuring rational use of antibiotics. The study aimed to assess the knowledge, attitude, and practice of antimicrobial prescription among doctors in the outpatient departments of Lagos University Teaching Hospital Idi-Araba. Methods: This was a cross-sectional study conducted consecutively among 259 doctors in the outpatient departments of LUTH. Data entry and analysis were performed using Epi info software version 7. The level of statistical significance was at P < 0.05. Results: The mean age of the respondents was 33.5 ± 6.9 years. Majority of the respondents were males (58.7%). One-third (39%) had between 6 and 10 years of work experience. One-fifth (20.8%) of the respondents were from the department of surgery. Almost all (98.8%) had an overall good knowledge of antibiotics. Majority, (95.4%) had a good attitude towards prescribing. Two-third (63%) requested for a laboratory test before prescribing. However, less than half (44.4%) prescribed based on guidelines and more than half (56.8%) had received trainings on antibiotics prescriptions. Two-third (63.7%) of the respondents had good prescribing practices. There was a statistically significant association between the years of work experience and knowledge of prescribing antibiotics (P = 0.036). Conclusion: Majority had good knowledge and positive attitude toward prescribing. The severity of infection, availability of the drug, cost of the drug, and clinical response of the patients were the major predictors of antimicrobial prescription of the respondents. Antimicrobial stewardship programs should be enhanced and antibiotic surveillance should be improved.

Keywords: Antimicrobials, attitude, knowledge, outpatients, prescribing practices


How to cite this article:
Akodu B, Bisola R, Temitope LA, Abdulrazzaq L, Philip O, Ibukunoluwa B, Patrick O, Olufunmilayo OA, Ganiya O, Chioma O, Oyinlola O. Knowledge, attitude, and prescribing practices of antimicrobials among doctors in the outpatient departments of Lagos university teaching hospital Idi-Araba: A cross sectional study. J Clin Sci 2022;19:22-30

How to cite this URL:
Akodu B, Bisola R, Temitope LA, Abdulrazzaq L, Philip O, Ibukunoluwa B, Patrick O, Olufunmilayo OA, Ganiya O, Chioma O, Oyinlola O. Knowledge, attitude, and prescribing practices of antimicrobials among doctors in the outpatient departments of Lagos university teaching hospital Idi-Araba: A cross sectional study. J Clin Sci [serial online] 2022 [cited 2022 May 28];19:22-30. Available from: https://www.jcsjournal.org/text.asp?2022/19/1/22/339149




  Introduction Top


Rational drug use is defined by the World Health Organization as, a situation where patients receive medications appropriate to their clinical needs, in doses that meet their own requirements, for an adequate period and at the lowest cost to them and their community.[1] Rational use of drugs refers to the use of medications by patients according to their clinical needs, in doses that meet their own individual requirements, for an adequate period, and at the lowest cost to them and their community.[2]

Irrational use of antibiotics, usually overuse and misuse is currently of increasing global threat.[3] Antimicrobial prescription becomes inappropriate when there is overprescribing, prescribing an antibiotic that is the majorly broad spectrum for an infection that ought to be treated with a narrow-spectrum antibiotics, inappropriate dosage or route of administration, poly-pharmacy and patients not completing their treatments.[4] In the outpatient settings, irrational prescription of antibiotics is more evident and the majority of the antibiotics prescriptions are written by general physicians.[4] When laboratory tests are not done to confirm infections, usually, it leads to the prescription of antibiotics for viral respiratory infections such as viral bronchitis, sinusitis, and otitis.[4] Inappropriate antimicrobial prescription is a major contributor to the increased rate of antimicrobial resistance, globally.[5] Irrational prescription of antibiotics also leads to adverse drug reactions, wastage of resources in the form of health-care costs as well as increased mortality.[3] Half of the prescriptions are unnecessary and inappropriate.[6] Antimicrobial prescription is affected by various factors such as the patient characteristics like the socio economic status, age and comorbidity in patient; the physician factors such as the experience of the physician, source of updating knowledge, influence of medical representative; quality of antimicrobial drugs as well as the availability.[7] Important factors that influence the doctor's prescribing behavior include patients' expectations, severity and duration of infections, uncertainty overdiagnosis, potentially loosing patients, and influence of pharmaceutical companies.[8] Good prescribing has been defined as the one that involves the recommendation of medicine appropriate to the patients' condition and also reduces to the minimum, the risk of undue harm from it.[1] Good prescribing achieve four main aims which include maximized effectiveness, minimized risks, minimized costs, and respect for the patient's choices.[1]

Criteria for rational prescribing as indicated by the WHO[1] include an appropriate indication, appropriate drug, appropriate patient, appropriate information, and appropriate monitoring.

Irrational prescribing is a term that is used to refer to authorization of medicines that is not in accordance with the good standards of treatment.[1] The various types of irrational prescribing include under-prescribing, over-prescribing, incorrect prescribing, extravagant prescribing, and multiple-prescribing.[9] The outpatient departments provide ambulatory care including diagnostic and treatments services, follow-up of patients after discharge from the wards as well as other promotive and preventive health services.[10] They are important constituents of the health care system and the majority of patients in the inpatients departments are from the outpatient departments.[11] Research on antimicrobial prescription patterns is particularly important in the outpatient departments because they are the first meeting point between a patient and the hospital.[11] Knowing the practice of antibiotic prescribing in outpatient settings is a major step towards ensuring an improvement in the use of antibiotics therapy.[12]

The study aimed to assess the knowledge, attitude, and prescribing practices of antimicrobials among doctors in the outpatient departments of Lagos University Teaching Hospital, Idi-Araba, Lagos State.


  Methods Top


Lagos University Teaching Hospital Idi-Araba is a center with a very high referral of infectious diseases from other hospitals. LUTH has a comprehensive Diagnostic Centre and VIP Clinic, state-of-the-art Laboratories, Radio-diagnosis, Radiotherapy, and Renal Dialysis facilities.[13] There are different specialties in the hospital that provides Medical, Surgical, Pediatrics, Obstetrics and Gynaecology, Radiology, Microbiology laboratory, Physiotherapy, Ophthalmology, and Dental services. This study was carried out in the General, Medical, Surgical, Obstetrics and Gynecology, Pediatrics, Dental outpatient departments as well as the Ophthalmology and Oncology departments.

Ethical consideration

Ethical approval was obtained from the Health Research and Ethics Committee of Lagos University Teaching Hospital with assigned no: ADM/DCST/HREC/APP/465. Written informed consent was obtained from each of the participants.

Study design

It was an out-patient hospital-based cross-sectional study.

Inclusion criteria

Medical doctors (males and females) working in the outpatient departments of Lagos University Teaching Hospital, Idi-Araba.

Determination of sample size

The sample size was determined using Cochran's formula:[14]

n = z2pq/d2

where, n = minimum sample size when the study population is 10,000.

z = normal standard deviate at specified level of significance 95% = 1.96.

P = 53.7% (0.537), this was based on a study carried out in Owerri, Nigeria.[15]

q = 1-p; 1–0.537 = 0.463

d = degree of accuracy desired = 0.05



n = 382.06

Estimated sample size = 382.

Since the study population is lesser than 10,000,

nf = n/(1 + n/N)

where nf = 382 and N = 800

nf = 382/(1 + 382/800)

nf = 259

The estimated minimum sample size was 259.

Data collection

It extended from July 2019 to January 2020. A self-administered, semi-structured questionnaire that was adapted from reviewed literatures based on the objectives of the study was used.[16],[17] The questionnaire comprised of socio-demographic characteristics, the knowledge of antibiotics and antibiotic resistance, the attitude of the respondents toward prescribing antibiotics and the practice of antibiotics prescription among the respondents.

Data management

Scoring and grading systems

A scoring system was used to assess the knowledge and attitude of the participants towards the prescription of antibiotics. In assessing knowledge, for every correct response, one (1) point was awarded. For every wrong or non-response, zero (0) point was awarded. The total maximum score was 18 and the total minimum score was zero (0). Using 50% as the cut-off, the total score of each respondent was converted to a percentage and graded as poor knowledge if <50% and good knowledge if ≥50%.[18]

In assessing the attitude towards the prescription of antibiotics, the 5 points Likert Scale was used. Strongly agree was awarded 5 marks; Agree-4 marks; Undecided-3 marks; Disagree-2 marks; strongly disagree-1 mark. The attitude section contained 12 questions, therefore the total maximum score was 60 and the total minimum score was 12. Using 50% as the cut-off, a score <36 was graded as a poor attitude and a score of 36 and above was graded as a good attitude.

In assessing the practice of antimicrobial prescription, the raw score method was used. For every correct response, one (1) point was awarded. For every wrong or non-response, zero (0) point was awarded. The total maximum score was 8 and the total minimum score was zero (0). Using 50% as the cut-off, the total score of each respondent was converted to percentage and graded as poor practice if <50%, (score lesser than 4) and good practice if >50% (score of 4 and above).

Data analysis

Data collected were checked for correction and completion. It was analyzed electronically using Epi-info 7.2.3.1 software program. The quantitative data were presented in tables and analyzed as descriptive frequencies and proportions. Association between knowledge, request for laboratory test and sociodemographic variables were tested using Chi-square and Fisher's exact test. A P < 0.05 was considered statistically significant.


  Results Top


Majority (54.4%) were between the ages 31 and 40. The mean age was 33.54 ± 6.9. Most (58.7%) of respondents were male while females make up the remaining 41.7%. The predominant ethnic group among the respondents is Yoruba (62.2%). Most (35.1%) of the respondents were Registrars, however, the Senior Registrars constitute 31.3%. Majority (39%) had between 6 and 10 years of work experience and 37.1% had <5 years work experience. This socio-demographic distribution is depicted in [Table 1]. Majority (98.8%) of the respondents had an overall good knowledge on antibiotics while only 1.2% had poor knowledge. Majority (95.4%) of the respondents had an overall positive attitude toward prescribing antibiotics while only 4.6% had a negative attitude. Majority (63.7%) of the respondents had an overall good antimicrobial prescribing practices and 36.7% had poor prescribing practices
Table 1: Sociodemographic characteristics of respondents (n=259)

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[Figure 1] shows that one-fifth of the respondents (20.8%) were doctors in the department of surgery while 16.2% were in the department of obstetrics and gynecology. Respondents in the department of dentistry and department of internal medicine were in the same proportion which is 15.1%. Only 7.3% of the respondents were doctors in the department of pediatrics. Others (17%) were in the department of Oncology, Ophthalmology as well as Medical microbiology and parasitology. [Table 2] shows the respondents' sources of information on antibiotics and how they rated these sources based on their usefulness. The most frequent source of information is the antibiotic guidelines (66%), followed by courses and workshops (48.6%). Most (76.8%) considered information given by colleagues useful and 71.8% considered information from antibiotic guidelines very useful.
Figure 1: Medical specialty of respondents

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Table 2: Source of information on antibiotics and their usefulness (n=259)

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Majority (86.9%) stated that it is better to ensure that a patient is cured of infection when in doubt by using broad-spectrum antibiotics and 75.7% of the respondents reported that antibiotics are not often prescribed because it is impossible to track the patient [Table 3]. Most (77.2%) of the respondents do not consider it best to prescribe antibiotics when in doubt as to whether it is a bacterial disease. About two-third (65.6%) have guidelines and more than half (52.1%) have policies for prescribing antibiotics. Most (62.9%) routinely requested for laboratory tests before prescribing and more than half (56.8%) have received training on antibiotics.
Table 3: Attitudes of antibiotic prescription among respondents (n=259)

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Concerning the frequency of prescription, 32% prescribed more than once daily whereas 22.4% prescribed 3–4 times/week. Majority (66.8%) of the respondents stated that their prescription is based on clinical judgment and less than half (44.4%) on guidelines. A large percentage (81.5%) prescribed both generic and branded forms of antibiotics while only 15.4% prescribed generic forms exclusively [Table 4].
Table 4: Pattern of antibiotics prescription among respondents (259)

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Out of the 96 respondents that do not routinely request for a laboratory test before prescribing antibiotics, 29.2% stated that this is because results are always delayed and 26% considered clinical diagnosis sufficient for their patients while 8.3% stated that the patients cannot afford the tests [Table 5].
Table 5: Respondents' reasons for not routinely requesting for laboratory tests (n=96)

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More than 84% of the respondents considered the severity of infection before prescribing antibiotics, followed by the availability of drug (79.2%) and the cost of drug (75.3%). More than two-third (68%) of the respondents are influenced by the clinical response of patients. The two modes of payment listed; out-of-pocket payment and national health insurance scheme are considered by 64.9% and 64.1%, respectively [Table 6].
Table 6: Factors considered by respondents before prescribing (n=259)

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[Table 7] shows the association between the sociodemographic characteristics of respondents and overall knowledge of antibiotics. There is a statistically significant association between the age of respondents (P = 0.036) and years of work experience of the respondents and the overall knowledge (P = 0.049). Respondents that are 31 years and above as well as respondents that have worked for 5 years and above are more likely to have good knowledge regarding antibiotics. However, the gender and cadre of the respondents were not significantly associated with the overall knowledge.
Table 7: Association between socio-demographic characteristics of respondents and knowledge of antibiotics

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This shows that the sociodemographic characteristics of respondents and the proportion of respondents that routinely requested for laboratory tests are not significantly associated [Table 8].
Table 8: Association between laboratory testing practices and sociodemographic characteristics of respondents

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  Discussion Top


Sociodemographic characteristics of respondents

Majority (58.7%) of the respondents were males while 41.3% were females. This is in line with the findings in studies carried out in another Nigeria tertiary hospital where 64.3% of the respondents were males.[19] However, the findings from this study contrasted with the studies in Malaysia and Ghana where females make up 71% and 59% of the respondents respectively.[20],[21] Out of the respondents, one-third (35.1%) were registrars while 31.3% of them were senior registrars. This is similar to a study carried out in a tertiary hospital, Nigeria where 48% of the respondents were registrars.[19] About 63% of the respondents had a work experience of >5 years. This is closely similar to the 65.3% obtained in a study in Peru.[22] This is likely due to the similar sample sizes. However, this contrasts the study in Khartoum where the majority (92.3%) had work experience between 1 and 4 years.[23]

Knowledge of antibiotic prescription

Majority (98.8%) of the respondents have good knowledge on antibiotics. These findings from this study are much higher compared to the study carried out in Ebonyi, Nigeria where only 64.7% of the respondents have good knowledge regarding antibiotics use and resistance.[24] This is likely because the study in Ebonyi was carried out among prefinal and final medical students while this study was carried out among doctors with work experience.

Majority (93.8%) knew that antibiotics could not be used to cure viral infections. This is distinctively higher than the 55% in a study in Pakistan.[16] This may be because almost half of the respondents in this study were made up of senior registrars and consultants who could have attended more courses and workshops. The contributing factor for resistance was admitted by 99.9% of the respondents to be self-medication by the patient followed by 99.2% who considered patient not finishing treatment as a factor. This is similar to a study carried out among medical officers in Malaysia where 92% of the respondents viewed self-medication as a factor leading to resistance.[20] Whereas, 94.1% of the respondents in a study in Pakistan stated that patient not finishing treatment was a contributing factor of resistance.[16] Reliance on expert opinion among respondents with prolonged work experience may account for this disparity. This study showed that the most frequent source (66%) of information is the antibiotic guidelines, followed by courses and workshop (48.6%). This contrasts with studies in Malaysia and Pakistan where 89% and 96% of the respondents reported respectively, that the internet is the most frequent source of information on antibiotics.[16],[20] This may be due to ease of access to internet sources in Asia countries.

As regards significant associations, this study showed that there is a statistically significant association between the age of respondents (P = 0.036) and years of work experience of the respondents, and the overall knowledge (P = 0.049). This indicated that respondents who have worked for 5 years and above were likely to have good knowledge of antibiotics prescribing, probably as a result of the exposure to the trend of antibiotic resistance in their practice. This however differs from the studies in Pakistan (P = 0.720) and Congo (P = 0.19) that showed that there was no significant association between years of work experience and knowledge score.[6],[25] This is attributable to inadequate exposure to academic meetings, courses and workshops in Pakistan and Congo.

Attitude of respondents towards prescribing antibiotics

Majority (77.2%) of the respondents in this study strongly agreed that it is important to know the resistance rate of bacteria. This is similar to a study in Khyber Pakhtun Khawah, Pakistan where 95% of the respondents agreed that knowing the resistance rate of bacteria is important.[6] This may be as a result of high level of knowledge among the respondents. Also, this study shows that more than half (52.3%) disagreed with finding it hard to prescribe the right antibiotics. This is similar to a study in Peru where 69% disagreed with finding it hard to prescribe the right antibiotics.[22] However, this study differs with the study in Lao People Democratic Republic where most (72.5%) of the respondents found it hard to prescribe the right antibiotics.[26] This may be attributable to a low level of knowledge among the respondents. About two-thirds (66.4%) of the respondents in this study strongly agreed that culture and sensitivity testing is important for prescribing while 38.2% disagreed that it is useful to wait for microbiology results when treating infectious disease. This is quite low compared to the study in Assam, India, which showed that 92.1% of the respondents agreed that culture and sensitivity test is important.[27] Antibiotic policies in the Indian study may account for these discordant results. This study showed that majority (64.9%) of the respondents strongly agreed to the implementation of a training program on antibiotics. This is much lower than that of the study in Kedah, Malaysia where 97% of the respondents agreed to the implementation of a training program.[20] This is likely due to the higher percentage of respondents (24.3%) in this study that were very confident, compared to the study by Tan et al.[20] More than half (53.7%) of the respondents in this study considered the unnecessary prescription of antibiotics harmful to the patient. This is similar to the 72.3% obtained in a study by Thriemer et al.[25] Whereas it contrasts the study by García et al. where only 25% considered the unnecessary prescription of antibiotics harmful to the patient.[22] This disagreement may be due to low knowledge of participants in the study by García et al. From this study, less than half (42.1%) of the respondents agreed that local guidelines were more useful than international guidelines. This is low compared to a study in Riyadh, Saudi Arabia where 66.7% viewed local guidelines as being more useful than international guidelines.[28]

This may be due to higher adherence to institutional policies in Riyadh.

Practice of antibiotics prescription among the respondents

In this study, 66.8% of the respondents prescribed based on clinical judgment and 44.4% based on guidelines.[29] This is relatively low compared to a Nigerian study where 93.9% prescribed based on clinical judgment.[7] This high proportion of respondents practicing clinical judgment-based prescription may be due to nonexistence or nonfunctional guidelines. Concerning the frequency of prescription, 32% prescribed more than once daily whereas 22.4% prescribed 3–4 times/week. This is similar to a study conducted in Pakistan where 33.8% of the respondents prescribed antibiotics more than once daily and 33.4% prescribed 3–4 times/week.[6] This similarity might be due to the high level of awareness of antimicrobial resistance among the respondents. The findings from this study is quite different from the study carried out in Kedah, Malaysia where more than half (52%) of the respondents prescribed more than once daily and 23% prescribed 3–4 times/week.[20]

This discordance may be due to lack of antibiotic prescribing policies in the Malaysian study. This study revealed that most (62.9%) of the respondents routinely requested for laboratory tests before prescribing antibiotics. This is similar to a study in South India where 51% of the respondents requested for laboratory tests before prescribing.[29] This may be attributed to better adherence to clinical guidelines by respondents in this study. This study however contrasts a cross-sectional study in Pakistan and another study in Punjab, Pakistan where none of the respondents routinely request for laboratory tests which was said to be due to inadequate laboratory services.[6] Majority (81.5%) of the respondents prescribed both generic and branded forms of antibiotics while only 15.4% prescribed generic forms exclusively and 3.1% prescribed branded forms only. This differs from the study in Yemen where 41% of the prescriptions were generic.[30] This may be as a result of strict adherence to antibiotic guidelines since guidelines are usually generic based. However, this study is similar to the findings in the study carried out in a Tertiary Hospital in Lagos, Nigeria where 72.4% prescribed generic and branded forms, 22.5% prescribed generic only and 5.1% prescribed branded only.[7] This remarkably high generic prescription may be a consequence of using National health insurance scheme policies that emphasize generic prescription. More than three quarter (84%) of the respondents considered the severity of infection before prescribing antibiotics, followed by the availability of the drug (79.2%) and the cost of the drug (75.3%). More than two-third (68%) of the respondents were influenced by the clinical response of patients. This is similar to a study in a Nigerian Tertiary Hospital where 70% considered the severity of the infections and 80.6% considered the cost of drugs and availability.[7]

This higher consideration for cost of drugs may be attributed to higher healthcare cost and inadequate access to National Health Insurance scheme.


  Conclusion Top


Majority of the respondents had good knowledge as well as a positive attitude towards prescribing. About two-thirds of the respondents routinely requested for laboratory tests before prescribing and for those that do not, their major reason was the delay in getting results from the laboratory. The major factors affecting the prescription of antibiotics by the respondents included severity of infection, availability of the drug, and cost of the drug as well as the clinical response of the patients. There was a statistically significant association between years of work experience and knowledge of antibiotics.

Recommendations

Guidelines and policies for antibiotic use should be developed and doctors should be encouraged to request for laboratory tests before prescribing antibiotics. Frequent workshops and seminars should be organized by the hospital in different specialties. There is a need to improve the efficiency of microbiology laboratory services and minimize the problem of delayed results.

Acknowledgment

The authors would like to thank the all doctors who voluntarily participated in the study.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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